Provider Demographics
NPI:1699715045
Name:CROSSROADS HOSPICE OF ATLANTA LLC
Entity type:Organization
Organization Name:CROSSROADS HOSPICE OF ATLANTA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-627-6846
Mailing Address - Street 1:10810 E 45TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3818
Mailing Address - Country:US
Mailing Address - Phone:918-627-6846
Mailing Address - Fax:918-627-6856
Practice Address - Street 1:1957 LAKESIDE PKWY STE 500
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5859
Practice Address - Country:US
Practice Address - Phone:770-270-9898
Practice Address - Fax:770-270-9896
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARREFOUR ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QH0002X
GA0200515330251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA050414737AMedicaid
GA050414737AMedicaid